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Senate | February 4, 2013 | Chamber | Session

Full MP3 Audio File

[Speaker Change] Senate will come to order. Sargent at Arms will close the doors. Members will go to their seats. Members and guest of the gallery will please silence all of their electronic devices. Leading the Senate in prayer this evening is Eagle Scout John Hip of Raleigh. And all members and guest of the gallery will please stand for prayer. [Speaker Change] Please bow your heads. Dear Lord, I would like to pray tonight for this General Assembly. I would like to thank you for all of the leaders and for all that they do for our State. I want to prayer for all of our leaders here, for you to protect them, and for you to bestow your incredible wisdom upon them. To help them to make the decisions that are right in your eyes. I would like to pray for the great State of North Carolina, that it might be a beacon, an example of truth, throughout the Nation. I also thank you for the wonderful organization of the Boy Scouts of America. I pray for the members of the Boy Scouts and thank you for all that they have done for young men like me. I thank you for the gift of internal life through your son, Jesus Christ. And for his death on the cross. We love you and praise you. In Jesus’s name we pray. Amen. [Speaker Change] The Sargent at Arms is recognized. Sargent at Arms will now open the doors for the presentation of the colors by the Honor Guard of the Boy Scouts of North Carolina. [Speaker Change] I plead of allegiance, to the flag, of the United States of America. And to the republic, for which is stands, one Nation, under God, with liberty and justice for all. [Speaker Change] We have a large contingence of Boy Scouts with us tonight up in the gallery. We would like to extend courtesies of the gallery to the Boy Scouts tonight and ask them to stand. Everybody else please be seated. Boy Scouts remain standing. We thank you for what you do, leaders of the Boy Scouts. We thank you Boy Scouts for what you do as well. You are the future leaders of this State and this Nation and we’re glad that you’re with us this evening. We would also like to extend courtesies of the gallery to the Conserved Medical Professionals for Healthcare Access. These are the doctors in the white lab coats in our gallery. If you would stand and recognized as well. We thank you for being here tonight as well. We would also like to extend courtesies of the gallery to David Thompson, Executive Director of the North Carolina County Commissioners Association. Is David with us this evening? David if you’ll please stand. Thank you for your attendance. Senator Phil Burger is now recognized for a motion. [Speaker Change] Thank you Mr. President. The journal of Thursday, January thirty first, two thousand thirteen has been examined and is found to be correct. I move that we dispense with the reading of the journal and that it stand approved as written. [Speaker Change] Without objection. The journal for January thirty first stands approved as written. A leave of absence has been granted for Senator Hartsell this evening. Our nurse for today is Cheryl Logan from Hickory. Cheryl, we thank you for being with us. Thank you for what you do as well. Moving on to the calendar for this evening. We have one item on the calendar. Senate Bill four. The clerk will read. [Speaker Change] Senate Bill four. An act, point one, to clarify the State’s intent not to operate a State run partnership.

Health benefit exchange. Two, to provide the future Medicaid eligibility. Determinations will be made by the state rather than the federally facilitated exchange. Three, to reject the Affordable Care Act ??? Medicaid expansion. [SPEAKER CHANGE]: Senator Apodaca is recognized to explain the bill. [SPEAKER CHANGE]: Mr. President, thank you very much. Members. I was driving down today and I was lucky enough to have my wife come with me, and all the way down the mountain, she’s telling me how I should drive. What I’m doing wrong. I’m going too fast, I’m too close to the center, I’m doing this, I’m doing that. We pull over and go to a rest area. And finally, I just said, you know what, if you can do it better, just drive. I’m tired of it. So she drove. But it reminded me of what we’re talking about tonight. Very similar to federal government coming down and saying, okay, we want you to do this, we want to be your partner, but you have to do it this way, we want to go this way, and we want to do. You know what, if you want to do it, do it the way you want to do it. Leave us out of the equation. And basically, that’s what this bill does. It’s not complicated. We’re just saying to Washington, if you want to do this, do it your way. Now this bill, as the bill reader read, it’s pretty self-explanatory. Part One specifically states no state exchange. Part Two, it does leave individual Medicaid eligibility decisions with the state of North Carolina, where it belongs. And part Three, optional Medicaid coverage will not be expanded. That’s the crux of this bill. The comments that we’ve been rushing this bill, we’ve done this, we’ve done that. Folks, this has been around almost three years now. We all know what’s in it. We all know about the Affordable Health Care Act, or as some of us call it, the Unaffordable Health Care Act. And we’re gonna find out as we go on down the road what this means to us. But tonight, this is what we have, and with that Mr. President, I’d like to, if I may, defer to Senator Brunstetter for a few more comments on the appropriation side of this, or lack of, and thank you. [SPEAKER CHANGES]: Thank you, Senator. Senator Brunstetter, you have the floor. [SPEAKER CHANGES]: Thank you. There is little question that Medicaid and our Medicaid overruns have dominated the discussions in this chamber regarding our appropriations budget and process. The problems that we’re having with Medicaid are a cancer that are affecting the rest of our budget. When we have to come in and bail out Medicaid, we’re taking money from every other priority that each of you value. The shortfalls have been around for a while. 2009 and ’10, 335 million; ’10 and ’11, 600 million; ’11 and ’12, 500 million. Serious short falls that require bailouts at the end of every year. Now the General Assembly is moving to fix Medicaid. This body, in the budget this past year, ordered an audit. And you saw the audit released by the state auditor last week, with a number of suggestions that I think the governors agreed with, and the new Secretary of DHHS has agreed with. And they’re starting to work on getting our Medicaid system fixed. We increased our staffing at the General Assembly and at the governor’s office, and expertise, so we could understand the Medicaid system and process better. Senator Apodaca mentioned that one of the problems is that our hands are tied by the federal government when it comes to managing Medicaid. Now, we have a history of very uncomfortable partnerships with the federal government, whether it’s in Medicaid or elsewhere. We’ve seen just recently long term delays on approvals of plan amendments when we try to manage our own program. We’ve seen them sue us, or threaten to sue us recently that is caused hundreds of millions of dollars in settlements. Now I appreciate the motivation of people who would like to see Medicaid expanded, and serve other North Carolinians. But, it seems to me that expanding Medicaid, which is a broken system, and broken process by over 30%, makes no sense at all. It’s going to result in that program imploding, and then nobody.

Representative: …is going to get the coverage they need. We need to get our Medicaid system fixed before we ever start talking about expansion. Speaker: Thank you senator. Any further discussion or debate? Senator Hines, for what purpose do you rise? Representative: To speak on the bill. Speaker: You have the floor senator. Representative: Ladies and gentleman of the senate, quite frankly, we as a state cannot afford the expansion of Medicaid and to issue a state based exchange. Estimates that we have from the department right now indicate that the expansion of Medicaid over the first seven year period will cost us and addition $1 billion in state funds $600 million of that will come from a wood working effect: individuals who are eligible under the current system, but not covered, when they come in under the new eligibility, are not reimbursed at the higher federal rate, but at the current rate. We also have $400 million, over that same time period, in additional costs that are not reimbursed by the federal government in the first few years. The real costs come in 2020, when we do not know what the reimbursement rates will be. Just to drop that to the 90% rates, starts adding $100 million more a year that we are required to come up with just to make these payments. You find the same existing under our exchange. Current estimates to run an exchange in NC is $100 million a year in operation in the firs year, that grows exponentially. The costs will be asked to pass onto the tax payers. Now the federal government comes along with both programs with some nice baits and switches: numbers of 100% reimbursement for the first year, the second year, or grant money that makes it all possible, but that goes away, that disappears, and we will continue to saddle the citizens of this state with a large burden that we did not for, but will be required to make those additional cuts to make it happen. Just last week, we saw in our department, which, in general says, if nothing else, that we cannot run our current system in an efficient manner. Why do we want to begin to believe that we can undertake such a massive expansion of a broke system. Speaker: Senator McKissick, for what purpose do you rise? Representative: To speak on the bill. Speaker: You have the floor senator. Representative: Senator Hines you ask that rhetorical question: should we expand Medicaid; but I would reverse it: why shouldn’t we cover 500,000 people in this state that currently do not have health insurance coverage - 95% do not – 500,000 people you are talking about? What will the burden be upon our hospitals in this state who are providing care, because one thing we know sir, is that when this affordable care act was passed, it was logically assumed by the states that it was bad Medicaid. If it does not happen then the money that goes to the hospitals to help them provide, will be substantially reduced an eradicated. The care that they provide will provide a substantial burden and hardship for many of those institutions, particularly the institutions in rural areas which unduly care for those in the state. So, do we have a duty? Do we care about what happens to them, because those subsidies, there in the past, will not be there. This is going to put a distortion on hospitals that were so deeply concerned about not expanding Medicaid coverage, that many of them came together and explored the idea of what they could do to make it happen. Many of them even explored the concept of coming up with a whole harmless concept so they would not be burdened in the event that after that period

That federal subsidies exist today, that they will reduce. Right now we do know under federal law the first three years cover 100% in its entirety. And after then, you’re looking at the states only paying, this state only paying potentially 10%. If you look at the numbers as well, over that first 5 to 7 year period you’re talking about in terms of the impact Medicaid expansion. We know that about 2 billion dollars a year is going to come into this state. 2 billion dollars, of which 1 billion will be net disposable income. In the pockets of individuals who’re employed in health care related fields. That can go out and help this economy in this state become more robust. In that same window of time, what do we know? Over 23,000 people will be employed in these related fields. 23,000 people. That’s a significant number. So we get many benefits. The benefits that come from the economic expansion, the benefits in terms of inviting care for those today that do not have care. Who are leaving the hospitals in the state and the burden of providing ?? care. If you think hard and long about what’s in our interest, what’s in the interest of our citizens. That’s what we need to be examining. I received a letter today from Representative, from Governor McCrory’s staff. Suggesting that maybe we should take a wait and see position and study this a little bit longer. When this thing came up in Committee there wasn’t a single stake holder group that was allowed to speak on this bill. Not a single one. It was difficult even getting the Department of Insurance the opportunity to speak. We need to listen. We need to hear what their words will be. We need to reflect upon the far reaching implications that the failure to expand Medicaid will have upon this state. Because if we sit back and we look and we think and reflect, I think the decided and deliberate decision will be made that it is in our best interest. Our vested self interest to do so. Can the administration of Medicaid be approved? Absolutely, positively, without a doubt. Not just in North Carolina but throughout the United State of America. And we should seriously accept our responsibility and challenge in doing so. But don’t throw the baby out with the bath water. Look at what you’re doing to the people who can benefit from this. That’s what we need to be considering. And when it comes to a health exchange, if we have the ability, to have autonomy and control and to influence those insurance products that are offered in this state, to do it in a way that would benefit us, why should we not do so? Why should we secede that control? Would you suggest we do that also in the Department of Agriculture? Why do I use that as an example? Because we have meat and poultry inspectors in this state that they hire, they do a great job with. But we don’t have to have them. We can save the money. We can relinquish that control to the federal government. Would you have us do that too? And there’s a host of examples throughout state government that I’d be happy to meet with you and share with you information about. Having that control, having that autonomy, having the capacity to better serve our constituents and to serve the residents of this state should be what our responsibilities are as members of this body. And I would hope and I would reflect and challenge each and every one of you to look in your hearts and souls. And to think about the duties that you were charged with when you took that oath of office so recently in this very chamber. In the last 30 days and say, do we not have a responsibility to those that are uninsured? To see that they continue to have care. To make certain that the ?? are provided for in a mean, reasonable, fair way as it was contemplated when the Affordable Care Act was passed. And I would hope that if we listen to those voices, reflected upon what we should do, that we should offer a state basis exchange or a hybrid model and its ?? Medicaid in the way it was anticipated when this bill was first passed. [SPEAKER CHANGES] Mr. President? [SPEAKER CHANGES] Senator Brown, for what purpose do you rise? [SPEAKER CHANGES] Speak to the bill. [SPEAKER CHANGES] You have the floor, Senator. [SPEAKER CHANGES] One of the issues and I think Senator McKissick just touched on it was about jobs and I’d say the stimulus fallacy of that.

Think about it. When does adding a billion dollars in state healthcare cost and piling up new responsibilities with regulations and rules on a mismanaged bureaucracy create any kind of jobs? Think about that. And we’ve heard these type of job arguments before in Washington with the stimulus plan that was passed not too long ago, and I think they were wrong then as they are now. It’s kind of like taking a shovel full of dirt out of a hole, walking around to the other side of it filling the dirt back in, and then announcing that you’ve somehow dug your way out of the hole. These arguments are all based around a misconception that Washington can simply send us federal dollars that we can use to stimulate the economy and fund jobs, but we know differently. At the end of the day, this is money that’s coming out of the taxpayers’ wallets. If the federal government’s giving us money, it will eventually and inevitably have to be made up for with higher tax burdens and higher premiums for the private sector, the very people we need to be encouraging to create jobs. This isn’t a job creator; it’s a job killer. Then let’s talk about the crowd out effect that this will do. Expanding government-run Medicaid will have harmful effects on private insurance because it will encourage many employers to drop coverage for their employees that meet Medicaid’s new eligibility standards. That’s something I’ve already talked about with my CPA. What am I going to do to deal with it in my business? What’s the least expensive way for me to handle it? Studies from MIT and Harvard researchers show that Medicaid expansion will actually have a relatively small effect on the number of uninsured, with about four fifths of the expansion coming from the crowding out of private coverage. That’s the wrong approach. Rather than throw more people into a broken Medicaid system that costs a lot of money and doesn’t provide the best outcomes, what we should be doing’s making the private markets work better. Another issue’s this employer mandate. Like in the Obamacare, exchanges could stop North Carolina employers from having to pay punitive tax hikes under the law’s employer mandate. These new taxes totaling as much as three thousand dollars per employee per year would be a burden on employers. They would be forced to use money that could go otherwise to be used for salaries, benefits or investments. Three thousand dollars per employee. The law stipulates that the tax applies only in an exchange established by the state. It makes no mention of federal exchanges, so by choosing not to expand, we could potentially be saving our businesses tens of thousands of dollars per year, which for many businesses could be the difference between staying open or closing their doors. What does that do for job creation? And I can tell you, I know a lot of businesses that are on the edge on this mandate for insurance, and a lot of them aren’t sure if they’re going to be around, and I’ve heard a lot of them talk to me about it. It’s a serious issue to think about. [SPEAKER CHANGES] Mr. President? [SPEAKER CHANGES] Senator Stein, for what purpose do you rise? [SPEAKER CHANGES] To debate the bill. [SPEAKER CHANGES] You have the floor, Senator. [SPEAKER CHANGES] Thank you. Senator Brown appears to be wanting to revisit the Affordable Care Act, and I’m sure that if you all could legislate that away, you would, but we can’t because that is the law of the land, and as part of the Affordable Care Act, there are a number of different revenues put on North Carolina workers, North Carolina businesses to pay for it, and that is our taxpayer money. It’s our taxpayer money whether it goes to the federal government or the state. It’s money that we pay in. By foregoing this Medicaid expansion, what ya’ll are saying is we’re going to have North Carolina taxpayer money paid to the federal government go to insure people in Arizona, in Nevada, in Ohio, in North Dakota, all of which, by the way, have Republican governors and are expanding Medicaid because they realize it is critical for the economic health of their states as well as the physical health of the people. Senator Brown said “How does this help the economy?” Well I’ll tell you how. Because on a gross dollar basis, if you factor in just what does North Carolina have to contribute in Medicaid match over the next eight years, it’s 840 million.

Right? What does that draw down? 15.8 billion dollars from the federal government paid for by North Carolina taxpayers. So you are all rejecting money that we as North Carolina taxpayers have paid to the federal government. That's about 16 billion dollars in economic activity. There's been a study done by a consulting firm that analyzed what are the economic impacts of that money. It comes out to about 1.5 billion dollars to the state GDP each year for the next 8 years. I really look forward to what ideas you come up with this session that will result in 1.5 billion dollars in GDP growth to the state of North Carolina; that will result in 23,000 new jobs here in North Carolina. This is money that will go to insure healthcare in rural communities. Rural hospitals are genuinely at risk once they lose that federal contribution for uncompensated care, which they will. And they have still a large number of uninsured people coming through the door. How are they going to pay for it? Either they're going to go out of business or they're going to demand more out of their insured population. That's you and me, those of us who are fortunate enough to have health insurance. That will end up raising your and my premiums approximately 1,000 dollars to pay for that uncompensated care. This is a deal that is good for the economy and good for the people of North Carolina. We have the opportunity to expand the GDP and increase jobs. We have the opportunity to save 2,800 lives a year quoting a Harvard study. There was another one that showed when you increase healthcare insurance coverage, people get more treatment or they go to the hospital. And what happens today is either they don't go to the doctor or when they do go to the doctor, they can't afford the prescription drugs or the treatment necessary to address whatever their health problem is. If we expand access, we are saving North Carolina lives, 2,800 a year. We can leverage 15 billion in federal money paid for by us, you and me. And we can avoid imposing a hidden tax on existing people with health insurance. Let us not miss this opportunity. Let's vote against this legislation. [CHANGE SPEAKER] Mister President [CHANGE SPEAKER] Mister President [CHANGE SPEAKER] Mister President [CHANGE SPEAKER] Ladies and gentlemen of the gallery, I please ask you that you hold your applause. You are here as guests of the Senate. This is not a time to cheer or applaud any senators but to be here as guests. So we please ask you that you do that. Senator Graham, for what purpose do you rise? [CHANGE SPEAKER] To speak to the bill. To speak to the bill. [CHANGE SPEAKER] You have the floor, Senator. [CHANGE SPEAKER] Thank you sir. On Sunday morning I woke up and read my Charlotte Observer in the editorial section and my good friend from Hendersonville, Senator Apodaca, was there. Great picture. And the topic was Should North Carolina Expand Medicaid? He voiced his opinion, more eloquently in writing than he did today. But there was someone who said we should do it, a doctor Jessica Saxe. She said she had a patient that came into her office and she said that the middle aged woman was complaining of chest pain under her chest bone. The lady had severe case of diabetes. She had high blood pressure. She had other risk factors that signify to the doctor that this lady could or was having a heart attack. So she tried to calm the patient and tell her that she needed to do a stress test as soon as possible so we can make sure that we prevent a catastrophic event in her life, her health. And the ladies retort was "can we do this next month?" because she simply couldn't afford the care. She said that's an ongoing and frequent occurrence in her office, that people needing medical care, healthcare, can't afford service. In North Carolina, we are the 12th

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the tune of hundreds of millions of dollars, by the expansion of this Medicaid coverage. The cost for Health Care for our prisoners, many of them will now be eligible for expanded Medicaid coverage, and that would be directly offset from our general fund expenditures, as well as the cost for mental health and substance abuse services that we now provide from our general fund, a significant amount of those costs will now be covered under the expansion of Medicaid, were we to do so. And, for our rural hospitals, our sheer survival to provide Medical Care for our rural communities is dependent on this expansion of Medicaid. As one hospital administrator put it, Medicaid payment is surely better than nonpayment. I strongly urge you to slowdown on this, to wait, and to relook at it to consider a method in which we can expand a Medicaid coverage under the affordable care act. I will be voting no on the bill. Thank you. [SPEAKER CHANGES] Mr. President. [SPEAKER CHANGES] Senator Kinnaird, for what purpose do you arise? [SPEAKER CHANGES] To speak on the bill. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Thank you, Mr. President. I've heard from many of my doctors, physicians. From pediatricians to family practice doctors. They're very concerned, I think you can see that these people have taken their time out, because they are concern. Physicians from hospitals across the state are very concerned, because they know the consequences. And they know the true costs. As senator Stein has said, all of us who have insurance will pay for it. But there are other costs that Senator Bryant referred to, the cost of ill health, which costs us more in the long run. Because by the time they get the care that they need, that they've put off because they could not get to the doctor, they cost us much, much more. And I think anybody who was associated with the hospital, I think senator Brunstetter knows that that is one of the true costs throughout this. I also want to talk to the point that senator Brunstetter said, that because of the expansion of Medicaid, we would have to cut other programs that we value. I value health care for all of my citizens, and my constituents value Health Care for all of our constituents. I've heard from them. I cannot tell you, there flooding into my office. I want to also say that this is a moral imperative. We owe everybody, as my constituents have told me, to share in what we have. And then, finally, senator Apodaca, you said this has been around for three years, but your governor hasn't been around for three years, and he has asked us to slow down. I ask us to slow down, also. [SPEAKER CHANGES] Mr. President. [SPEAKER CHANGES] Senator ??, For what purpose do arise? [SPEAKER CHANGES] Speak on the bill. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Thank you, Mr. President. Ladies and gentlemen of the senate, if we adopt this bill, we will be dropping a large rock into the pond that is North Carolina's Health Care System. And that boulder may cost, or will cause significant ripples throughout the system. And today, our governor asks us to stop, take some time, and examine those ripples. Whenever we may think about Medicaid, and we've heard many thoughts about that, reforming it, carefully auditing it, we cannot deny that it has become a central part of health care funding across the country, and in North Carolina. Now, as our state has grown, so have our residents' needs. Just for one example, the number of obese adults in North Carolina grew from 13% in 1990 to 30% in 2010. And 1/3 of our children ages 10 to 17 are overweight or obese. By not expanding Medicaid, we will needlessly squeeze the budgets of our hospitals, our clinics and other healthcare providers, forcing them to make difficult choices about eliminating programs ending patient care in some areas, and laying off employees at a time when our state's needs are getting greater. Now some have suggested tonight that Medicaid expansion will be a job creator, while

Others have disputed that. But I can offer you one certainty. Senator Brown alluded to it, but I'm gonna argue it on the other side. This bill will be a jobs killer. And I'll offer you another certainty, the financial pressure will be greatest on our rural community based hospitals and clinics. We've talked about this at a macro level, Senator Stein, Senator McKissick, Senator Brown, Brunstetter and others, but I want to take you to a micro level for a minute. Look at Person Memorial Hospital in my district in Roxboro. Of it's $85 million dollar budget, Person Memorial spends nine million dollars, more than 9% of its budget on indignant and charitable cases. Last year the hospital of its size had 21,000 emergency room visits. Person Memorial has been forced to eliminate some programs, among them I was really sad to learn, obstetrics. There's not a single obstetrician or OB practice in Person county. And the hospital has not delivered a baby in five years. This is forcing expectant mothers to travel to other counties to seek care if they are able to travel regularly. The surgery department rarely has more than a dozen surgeries scheduled in a week, and half the patient beds have been converted into long term care, a nursing home. Without an expansion of Medicaid Person Memorial will lose $800,000 in access funding as Senator McKissick alluded to, and even greater amounts to come. This will force the hospitals leadership to look carefully at all its programs and its staffing. With 330 employees and an annual payroll of $12 million dollars in Person county, Person Memorial is one of the county's largest employers. Personnel cuts will have a significant impact on this counties economy, not to mention the purchasing power with fewer programs. Now I share this case with you not just to point out another struggling hospital but also to shine a light on how approving this bill will jeopardize the much needed care for the residents of Person county, 18% of whom are uninsured. Ladies and gentleman I'm certain if you look around your districts and your counties, you will find equally critical and equally dire circumstances among your health care pr9oviders. Our failure to expand Medicare will also have a significant impact on our teaching hospitals. There's an increasing gap between the cost of residency programs and the federal reimbursement for graduate medical education that helps fund them. For instance last year UNC Hospital's training cost cost $43 million dollars, but the hospital received only $13 million in educational reimbursements. This situation is forcing our teaching hospitals to take fewer residents, further exacerbating our growing physician shortage.Our state's population is growing much faster than our ability to train professionals just like these men and women here tonight. And the physician shortage our state is experiencing is especially pronounced in two areas, the pool of primary care physicians, and in our rural areas. Increasing completion of graduate medical education has resulted in fewer than 10% of residents pursing careers in family practice. And that competition is also forcing new residents to practice in urban areas. In North Carolina, 20 counties don't have a single general surgeon, and in my Person county there is only one general surgeon. The gap in medical education funding is also affecting other medical professionals, such as physicians assistants and nurse practitioners. While these are the providers who've helped lesson the impact of the physician shortage in rural communities, there are now fewer of them and they are choosing to stay in urban areas more often. Turning our backs on Medicaid expansion will make this situation worse and worse, forcing patients, especially those in rural areas to have less access to health care. Ladies and gentleman of the senate, before you cast your vote on this bill, please check with the hospitals and clinics in your counties. Ask the CEO's the CFO's and the medical chiefs of staff...

...and even the frontline patient care staffs, about how rejecting Medicaid expansion will affect the quality and the quantity of patient care in your community. Ladies and gentlemen, before we drop that boulder in the pond, lets please understand the full impact of this action, because the ripples are washing up on all our shores. Thank you, Mister President. [SPEAKER CHANGES] Mister President. [SPEAKER CHANGES] Senator Robinson, for what purpose do you rise? [SPEAKER CHANGES] To debate the issue. [SPEAKER CHANGES] You have the floor to debate, Senator. [SPEAKER CHANGES] My colleagues, you've heard certainly from a lot of us about the concerns we have and one of the things that, and I won't repeat what has been said, but when all of us came here, we came here to serve our citizens. Not only in our communities, but across this entire state. And I have to reflect also on some of the other experiences. I remember years ago in Guilford County, and it's one of the more metropolitan counties, but even in Guilford County we had such a large number of people who were uninsured. And we had to develop what was called Health Serve. That was started with volunteer doctors and nurses to try to serve those people who didn't have insurance. And over the course of the years, it still takes volunteer doctors to help six different medical practices that serve 50,000 people who are uninsured. 50,000 people total, but 80 percent who are uninsured. A large percentage of those are adults with a lot of different illnesses. They don't just have diabetes. They have heart conditions. They have high blood pressure. All of those things, which means that if they show up on the doorsteps of the emergency room, which is what was happening, the cost of their care goes from 167 dollars per visit that Health Serve is paying now [??], to 800 dollars. The cost of uncompensated care in emergency rooms are high. Extremely high. And if hospitals in Guilford County can't afford it, I know that hospitals in rural areas can't afford it and they will go out of business. While we have 50,000 people in our county, we're talking about 500,000. A lot of those are low income and they're minority. And we know the proportion of health disparities is among minorities. Not only because of income, but because of lack of access. And I see that a lot in my job. People who come in for screenings, who are told "Why didn't you go to your doctor?", "I don't have a doctor, I don't have any money." And it's also a new group of people who are unemployed. When you become unemployed, you don't have any insurance because you don't have anything to pay for it with. So not only do we have those people that we've seen all these years, we've got new people now, who can't afford healthcare. Healthcare is preventive. If we insure these people, that's preventive. We will save our state millions and billions of dollars. If not, we will incur additional costs. Best is at [??], which is the parent of all of those six medical practices. Their budget is only 16 million dollars but they provided 24 million dollars in care, which means 8 million was uncompensated. So if that is the impact in Guilford, it's more across this state. I would impress upon you the importance of making sure that you neighbors, people you serve in your county, all people aren't the party you represent. They're different parties, some unaffiliated. They're different races. But they're North Carolinians who deserve to have preventive healthcare. And that's what Medicaid expansion's about. It's about prevention. If we prevent the diseases on the front end, we save money on the far end. And those are the people who go to emergency rooms and it certainly is going to put a lot of rural hospitals out of business. I know that in Guilford County, our county commission's not going to want to give any more money. They don't have it, and nobody else has it. So that means that a lot of other people...

that to the county of here's how to act as you said that neither party today that I'm finding that has issues into one of the shooting percentage and approve this is a human gene ?? is going again is not the 29th in tears about uprising has access into prepared by the time , he's got the name any happening that a zero and constantly busy in addition to an-time thing, the dark here to me that the preventing for that, for any company that has been arrested because it ?? is suppressing the incident was arrested a second, enforcing ??-seeming lack of interest to continue to be deeply concerned about to the loss for its continued work on the Times' defense that means that we have a division of lost $43,000,000,000 we've updated time essential and-a-week delay when he has a $75,000,000,000 a week trying to invade Iraq calls than it spent about $11,000,000 more than ever we pass this bill passes, drafted you have to come up with another time in the dollars it, we can least afford to better serve the final three million dollars in 1987 and well-represented the result is the first times are not the whole issue of ?? to that session that said the former Xerox-SD, mail and for some that has-high and has the same time with this, 8 to 9 in the wince embed his 18 the time-to-june where of wine festival features owner- Raton of time and have shown that we even copy and was widely known a ?? with a two-day-by-the-I'm-teens and, of Santa Ana, that have been about 10:00 of me that the document imaging and ?? I doubt that there are about 20 seven sometimes and have him hiding and the satisfy your of the age of 80 west, the defending ventures that the station ?? at the shoe fight, get caught up and that she has been able to get radiation readings are tiled din of chardonnay at a time when she sounds 100 at the end of Saturday to roll it back, junior cancer chime am a member of the investigation and I have added about $500,000 in and said nothing left it stops in San Diego and he was I said, is the sole time to acted on the side that when that anything that that with a family and your time-bop and eight, Saturday, Sunday, but I it's a dangerous, ?? of five years ago-day among the window and seeing the end of the Indian ?? at a lot of money out of the severity of the time came to an ??..................

When you have serious medical problems, and I'm a male and we all think we're tough. But if we think we got heart problems we need to be able to go to somebody and get it checked, and if we got a problem get it fixed. You can't just show up at an emergency room and get that kind of care. So understand what we're doing here. We got 500,000 people out here that can't take care of their spouse, they can't take care of their children, they can't take care of their grandchildren. They gotta take the scraps off the table and show up at the emergency room when the cancer, when they're bleeding in the rectum and the colon cancer is so far gone that they're gonna die because they couldn't go get a colonoscopy. That's what we're talking about here and I just felt like we ought to get, I don't, this isn't bleeding heart time. That is the truth and it kinda reminds me of the debate when all of us men gather round and start talking about women's reproductive health. We don't have the experience that these people have, keep that in mind. For most of you on the other side of the isle, you're from rural districts. Up in the mountain counties most of our rural hospitals now are associated with Mission hospital or with Charlotte Medical Center. East Carolina has six or eight affiliates that are rural hospitals down in the Northeast and I know that the state is like that now. These rural hospitals have had to go to them for help and they've kinda been absorbed. You need to sit down and have a serious conversation with them. If they lose their DSH money and the people coming in there are uninsured, there is a very good chance they will be closed. These big hospitals aren't altruistic they aren't doing it just for their health. They're doing it because it's profitable or in some cases not profitable but it sends patients to the mother ship and that's profitable. When they get to be a big enough burden they're gonna start shutting them down. Obama Care or Affordable Care or whatever you wanna call it is the law of the land and a lot of things are gonna happen. First thing is everybody would be insured, there's no reason to give you make-up money for treating non-insured people. The second thing that's gonna happen, the federally qualified health centers that a lot of us now have, there's one in ?? United Center off Dockers and there's one in Buncombe. That money is gone in 2014. Those are your free clinics and they aren't free, the federal government is funding them. They're gonna quit funding them. And if you don't insure these people, what I'm trying to tell you is the method that we now use of funding healthcare for the uninsured is going to go away and when it does you're gonna see, I think, catastrophic failure in your healthcare system. It wasn't anticipated that you would continue to have this large number of uninsured out here after it went into place. It was assuming that everyone or most everyone would be insured. The governor sent us a letter today and I think it's pretty clear that he says we need to move slower on this on all of this and take some time to figure out what we're doing and make sure we don't have unintended consequences that end up damaging the healthcare system for all of us. So I would ask you...we just got here, we just started Wednesday. Good gracious we're gonna be here till I heard somebody say May. We're gonna be here till June maybe July. We've got plenty of time to work on this bill, plenty of time to see what happens now that a number of states have said they're not going to participate in Medicaid. It's gonna be another shoe to drop. This bill needs to go somewhere and hibernate for a little while, it's not gonna get, it's not gonna change, ya'll got the votes. It's two to one, but time

[Speaker changes.]...might benefit everybody in this chamber and I urge you to vote against the bill tonight. [Speaker changes.] Senator Rucho, for what purpose do you rise? [Speaker changes.] To debate the bill. [Speaker changes.] You have the floor Senator. [Speaker changes.] Ladies and gentlemen of the Senate, I'll say to my friend, Senator Nesbitt, that each of us in this Senate are most concerned about the medical well-being of our citizens as well as the financial well-being of our citizens. In the state of...an ideal state, there is no poverty...unfortunately in this state, there is. And there is no problem with health and there is in this state. These are some things that this General Assembly and the Senate, under new leadership, will do everything it can to correct. Senator McKissick talks about the Affordable Care Act earlier...about a lot of assumptions that were there. I think the entire Affordable Care Act was assumption, since no one had a chance to read it. And then, secondly, as we learn day-by-day what the rules are, the regulations are being written up just as we speak, especially dealing with exchanges no one knows what the rules are. About how to run an exchange. This bill does nothing to prevent the federal government, who has decided to mandate us, that this country will have a national type of healthcare through this insurance package. To come forward in North Carolina, to organize the healthcare exchange, to operate the healthcare exchange, and, Senator Stein, even to pay for that healthcare exchange, since you're concerned about where that money is going. Those are all of our tax dollars. The issue dealing with disproportionate share of hospital money...that was a decision made many years back, was a bad decision and, again, the federal government decided or assumed that the states would accept responsibility for this again, recognizing that in our state, in the Medicaid system, the way it is today, and I know each of you that have been here at least one term, know that we spent five-hundred million dollars this last year trying to cover the overage in Medicaid. And I think it was three-hundred million the year before and it's not getting any better because it's out of control and it's very clear from Beth Woods' research..report...that it is not getting any better and really needs to be completely overhauled. And this is something that this General Assembly will take action in doing. To make sure that when we put money into a system, we know that we get return our investment. That means good healthcare, that means not rationed healthcare, that means quality healthcare to everyone as we can afford to do it. There are a lot of folks that say, just go ahead and, as they've done in the past, they say, "just go ahead and keep spending money that you don't have." Well, the constitution of North Carolina requires us to have a balanced budget and, in this situation, we in the General Assembly...at least the majority party here in the Senate, are going to live up to our responsibility of following the constitution and make sure that we don't spend money we don't have. That kind of attitude has put us into severe problems in the past few years, has only gotten worse and what we hope to see a "turnaround" as we've already seen in the last two years. We, in this General Assembly, should learn a lesson. You don't make promises...or you don't believe promises from the federal government. You look at what they've done to us with the insolvent...unemployment insurance fund, where we went 2.7 billion dollars in the hole. We're struggling today. Businesses, Senator Tucker, businesses are having to lay people off so they can make their unemployment benefits because we believed that the federal government was our partner, our friend...and we could trust them. You look at the Medicaid system, as it's already described earlier...500 million dollars was spent this last year and that's, from what I gather, 2-300 million more coming up this year because we can't control what the federal government says to us and, more importantly, we should never trust what they promise us. If they promised us they're gonna pay 100% for the first three years, and then maybe 90/10 as Senator McKissick alluded to afterwards, ya' can't bet on that. That means that we are gonna' accept responsibility for the costs. We, North Carolinians, who will have to pay taxes that we don't have that are burdening our economy today...we hafta pay more money for that and it's our responsibility in this General Assembly to make the right decisions and base it on the truth and base it on financial or economic facts...and that is, if you don't have money to spend on it and you know potential its there, you don't spend it. It's not up to us... [Speaker changes.] [Speaker changes.]

decisions that will potentially bankrupt the state budget. This system could do it as it is presently is structured, it makes no sense to put any more money into a system that you can't trust. Therefore, I will vote for this bill. [SPEAKER CHANGES] Any further discussion or debate. Senator Berger for a purpose to your eyes. [SPEAKER CHANGES] Speak on the bill. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Thank you Mr. President. Members of this senate, this bill does two things. The first thing that it does, is it says is that North Carolina will not move forward with the state based exchange. Fairly simple, that is the first thing it does. I haven't heard a whole lot of discussion about that, but that is the one thing. The second thing that the bill does, is it says, that with reference to the passage of this bill, there will be no medicaid expansion in North Carolina, but it goes on to say that no department, agency or institution in this state shall attempt to expand the medicaid eligibility standards provided in session law 2011 145 as amended or elsewhere in state law unless directed to do so by the general assembly. So Senator Nesbitt will always have the option to come back if for some reason the promises of the federal government seem to be better than they seem at this time. Too many people have been seduced by the lure of easy money from the federal government. They'll just promise anything, and they do, often. We have a medicaid system presently that is broken. It is eating us alive. Our inability to pay for the medicaid system we currently have is causing us to reduce expenditures across the state budget, or not have money that we would like to. And we're talking about adding to that, on the promise from the federal government that they'll pay for it for the first three years, and then all we have to pay for is ten percent. Well first of all, if you haven't looked, the federal government is running deficits at over a trillion dollars a year. They don't have the money. They have printing presses, but they don't have the money. And ultimately, if they had the money it would be coming out of the pockets of North Carolinians and folks across this nation. At some point people have to understand that there is no money tree. It just doesn't appear out of thin air. And quite frankly, we would need a forest of money trees to pay for what the federal government is trying to cram down our throats. I urge you to vote for the bill. [SPEAKER CHANGES] Is there any further discussion or debate. Hearing none, the question before the senate is the passage of the committee substitute Senate bill 4 on its second reading. All in favor will vote "Aye" (the green button). All opposed will vote "No" the red button. Ten seconds will be allowed for voting and the clerk will record the vote. 31 having voted in the affirmative, 17 in the negative. Senate bill 4 passes on its second reading and without objection will be read a 3rd time. [SPEAKER CHANGES] North Carolina ?? [SPEAKER CHANGES] Any further discussion or debate. [SPEAKER CHANGES] Objection. [SPEAKER CHANGES] Senator Nesbitt objects to.. [SPEAKER CHANGES] Its fine to… excuse me Mr. President [SPEAKER CHANGES] You have the floor, sir. [SPEAKER CHANGES] Would Senator Apodaca yield for a question? [SPEAKER CHANGES] Senator do you yield for a question? [SPEAKER CHANGES] I did [SPEAKER CHANGES] He yields, senator. [SPEAKER CHANGES] Senator Apodaca, I had understood that we would debate the bill today and tomorrow. Would you object to holding third reading until tomorrow. [SPEAKER CHANGES] This is a very important issue. I thought we had a pretty thorough debate, but we can hold it over until tomorrow, give us something to do on a nice ??. [SPEAKER CHANGES] Absolutely, I have nothing better to do Thank you. [SPEAKER CHANGES] Senator Apodaca, sorry, if you could repeat, I was in conversation up here. [SPEAKER CHANGES] Yes, Senator Nesbitt ?? third reading. [SPEAKER CHANGES] Nesbitt has rejected to third reading, so senate bill 4 will be placed on the calendar for tomorrow. A few moments ago, before we

As part of the calender I introduced the nurse of the day and she wasn't here, but she is with us now. Our nurse of the day, which we especially need on days like today, is Cheryl Logan. We thank you for being with us today and we appreciate what you do. We also have a special group of folks with us today. We have our pages here with us, I'd like to ask the pages that are here this evening to come forward on the senate floor and they will be introduced by the reading clerk, so if all of our pages will step forward please. [SPEAKER CHANGES] Pages ??, Alec Brown, Gary, Haley Jacobs, Nathan, Nicole ??, ??, Robert Fleming, Eli, Daniel Folger, Elan, Tory Jackson, Denver, Emma ??, Salsbury, Mark ??, Wilmington, Ross Sticklan, ?? [SPEAKER CHANGES] Pages we thank you for being with us for this week, and we appreciate the service that you're providing to the state and we hope that this will be a rewarding experience for you, and one that you'll remember for a lifetime, and even after this week we invite you back. Thank you for what you do and for being here. Are there any notices and announcements? [SPEAKER CHANGES] Mr. President? [SPEAKER CHANGES] Senator Nesbitt, with what purpose do you rise? [SPEAKER CHANGES] An announcement. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Yes, the democrats will caucus immediately after session. [SPEAKER CHANGES] Senator Tillman, with what purpose do you rise? [SPEAKER CHANGES] An announcement. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Tomorrow evening at 5 o'clock, begining at 5 o'clock, they'll be a fish fry and a pig picking at 1627 Navaho drive. Easy to get there, if you need directions I believe we've mailed them out, but if not get in set with my office and we'll, this is to honor our colleagues that have passed recently, Senator ??, Senator ??, and Senator Ed Jones. They were all close to the seafood industry and we wanna honor them, and respect their memory. We'll be doing that. [SPEAKER CHANGES] Thank you, senator. [SPEAKER CHANGES] Mr. President? [SPEAKER CHANGES] Senator Brunstetter, with what purpose do you rise? [SPEAKER CHANGES] An announcement please? Members, tomorrow there will be a joined appropriations budget presentation in room 643. That'll run from 8:30-9:45. We've had a couple questions regarding this. We're also going to be meeting in the same time slot on Wednesday. That time slot is there in case we can't get all the information in and questions answered tomorrow, so it will be different information on Tuesday and Wednesday, and we've also been asked whether attendance is mandatory on this. I don't know if anything is mandatory around here, but it is optional and all members are invited. [SPEAKER CHANGES] Senator Barringer, with what purpose do you rise? [SPEAKER CHANGES] For a matter of Personal Privilege, sir. [SPEAKER CHANGES] You have the floor for a matter of Personal Privilage, senator. [SPEAKER CHANGES] Thank you very much, I would like to wish our Senator David Curtis a very happy birthday. [SPEAKER CHANGES] Senator Davis, with what purpose do you rise? [SPEAKER CHANGES] An announcement. [SPEAKER CHANGES] You have the floor, senator. [SPEAKER CHANGES] Thank you, Mr. President. I'd like to invite former county commissioners that are part of the senate body to the joint legislative county coalition meeting tomorrow morning at 7:30 in room 1425. [SPEAKER CHANGES] Thank you, Senator. Any further notices or announcements? [SPEAKER CHANGES] Senator Apodaca, with what purpose do you rise? [SPEAKER CHANGES] Announcement, please? [SPEAKER CHANGES] You have the floor senator. [SPEAKER CHANGES] Members, tomorrow morning at 10 o'clock, room 1027 the rules and operations senate committee will meet, will be considering senate bill 10, eliminate obsolete boards and commissions, and we were gonna wait, but I think we'll have the bill enforced to invite the Governor

over something but we decided not to wait so we will probably have that bill tomorrow too thank you senator any further notices and announcements if not is there any further business to come before the senate if not the senator recognizes senator burger for motion Mr president i move that the senate be now adjourned subject to introduction of bills and resolution and the receipt from the governor and the receipt referral and re referral of bills convene tomorrow Tuesday January 5th 2013 at 9am and members the 9 am start time is going to be a skeletal session and we will take a recces until 3 the motion is that the senate be now adjourned to reconvene Tuesday January 5th at 9am subject to introduction of bills 2nded by senator obadacka all in favor say i oppose no the i's have it and the senate stays adjourn